Ruminations by a non-academic general surgeon from the heart of the rust belt.

Thursday, February 25, 2010

J.D. Salinger and the Doctors of Tomorrow

Jerome David Salinger died a few weeks ago at the age of 91. The famously reclusive author who chronicled the fictional exploits of Holden Caulfield and the precocious Glass children last published a work of fiction in the mid 1960's. For the past 40 years he has lived an anonymous, unassuming life in New Hampshire. I mean can you imagine an author/artist/actor at the top of his game in this day and age suddenly withdrawing from the public eye, never to be seen again? Rumor has it that Salinger never stopped writing, that his private archives contain volumes of unpublished material.

I'll get this out of the way in the beginning---I'm an unmitigated devotee of J.D. Salinger. I've read everything he ever wrote, multiple times. There's something slightly embarassing about that fact, I realize. Especially at my age. At the beginning of Hemingway's "The Sun Also Rises", Jake Barnes describes how Roy Cohn read a book called "The Purple Land" too late in life and was corrupted by its sentimentality and romanticism. Many say the same about Salinger's "The Catcher in the Rye". You're supposed to read it when you're a teenager, so you can identify with the adolescent angst and sense of betrayal that dawns on a young sensitive soul when he realizes the world is full of selfish phonies, but then you move on, to richer, more nuanced literary takes on human existence. It isn't meant to be a book for a mature sensibility; if anything it can be dangerous to read it when you're into your twenties. I gently disagree. It's a soulful, meaningful book that I plan on reading many more times before I die. I read about Holden Caulfield and Franny and Zooey and Seymour and all the other Glass children for the first time when I was 23 years old. I was living in my mom's basement, working at a lousy plastics factory during the day, waiting to find out if one of the medical schools in Ohio would accept me. I wasn't exactly feeling too enthusiastic about my future prospects. My friends had all seemingly moved on in life, consulting jobs and grad schools and such, while my life had stalled for the first time. Reading Salinger that year kept me sane and hopeful I suppose. When the phone call came in the early summer announcing that I had been accepted, I drove around like a madman, happy and delirious, sort of like Holden at the end of the novel, crying in the rain as he watched his little sister Phoebe spinning in circles on the Merry-Go-Round in the park. I couldn't exactly articulate why I was so happy, at that point. I had been chosen was all I knew. Chosen to embark upon a life of service and honor. And all that jazz. I think all medical students start out that way, wide eyed and humble and full of idealistic hope. But it doesn't last; life rolls on and consumes you and the next thing you know you're anxious about grades and AOA status and what specialty to pursue and which residency program to apply to and all these things that have nothing to do with Phoebe on the Merry-Go Round. Without losing those moments of inchoate happiness completely, a young doctor has to somehow figure out how he's going to go about fulfilling his promise to himself, his profession, and his patients. How should he go about being an actual doctor? With what mindframe ought he to adopt? Ecstatic joy is no match for the cruel grind of actual existence, the years on top of one another, the petty torments of human aspiration. You need a more enduring strategy.

There are talented, intelligent college students right now across this country considering whether or not to make a run at medical school. Nowadays, it isn't the slam dunk decision it used to be. If you were smart, top ten in your class, Dean's List--- medicine automatically went to the top of the list of possible career options. It had prestige. It payed well enough and possibly even better depending on what specialty you chose. It made your parents proud. It represented a low risk path to legitimacy in life, an assurance that your social standing wouldn't be contingent on such factors as personal relationships or fluctuations in the business cycle or mere chance. It just seemed to be a smart, conservative thing to do for an otherwise intelligent, hard working youth who harbored vague aspirations of "helping people".

Things have changed. (Not entirely; you're parents will still be proud of you.) But medicine isn't necessarily the default career pathway for a new generation of hard-working, intelligent Americans. Frankly, I don't know why anyone would want to pursue a career in medicine anymore. It's a tough gig, one that has lost luster over the past ten years. The pay isn't what it used to be--- there are pediatricians in this country who earn less than high school athletic directors. The debt one must take on to pay for medical school (close to $200,000) is simply absurd. And the prestige has correspondingly dropped. At some point in the near future, the local doctor will be perceived as a mere civil servant, a health provider who is seemingly interchangeable with other providers like nurse practitioners and physician's assistants and whatever other iteration of primary care develops in the future. And then there's the mentality in American medicine that errors and bad outcomes are unacceptable. We have "never events" now. Doctors order tests not to identify diseases necessarily, or to search for an unidentified source of a patient's discomfort, but rather to cover themselves from any future accusations that they "didn't do enough". There's an antagonism that has crept into the doctor-physician relationship, prompted by our corrupt medical malpractice system, unreasonable patient expectations, and physician cowardice and detachment that threatens to permanently blacken the soul of our profession. It's sad and depressing for those of us young enough to know we will have to wade through this transition phase for the next 25 years. For those who haven't committed yet, who stand on the brink of life with all its possibility and glory shining before them, medicine starts to seem far less appealing than other choices, even to the idealists.

But don't let the negative discourage you too much. Let me tell you a secret: this is still the best job in the world. And not because I'm a surgeon and get to do "cool procedures" and occasionally get to directly affect the course of a patient's life through a timely intervention. I like that part, don't get me wrong. I'm not some sort of Marcus Aurelius Stoic saint unperturbed by the dramatic viscissitudes of life, possessing such powers of self restraint that I refuse entirely to pat myself on the back occasionally. I'm only human. But when you do this long enough, you start to realize that whatever good you did for that patient, some other surgeon did just as well in the town next door, and if you weren't on call, whoever was would have done exactly what you did. You did your job, that was it. It wasn't about you. What you realize soon enough is that when you save someone or cure them of cancer, the lucky one in the transaction is you, buddy. Anyone can cut out a colon cancer. A million surgeons can do it with sufficient technical excellence. So don't go getting all high and mighty about it. You did your job as well as you could, based on your training and experience. No one would expect anything less. The patient would have been served just as well at another hospital. You are the one who ought always to feel privileged---that a patient would give herself to you, open her heart and soul, bare herself in all her failings and infirmities and suffering to this stranger who struts into her room in a white coat with all the answers and an indecipherable plan to somehow heal her pain. The sudden intimacy of the encounter is enough to stop your heart if you don't watch it. The trust and the view that our patients grant us is an incalcuable gift. We see humanity in these unvarnished, stripped down moments of vulnerability. Your gaze upon the stricken is a rare glimpse into the depths of what it means to be human. I like to think sometimes that heaven is all around us, if we look hard enough. I see it in my daughter every morning, standing in her crib in the morning dimness with those deep dark eyes of hers, looking up at me, the nascent beginnings of a smile forming in her lips. But too often we miss it in our everyday dealings. We miss it entirely, consumed as we are in our silly strivings and pronouncements and righteousness and posturing. We miss it all. But in the doctor-patient encounter, there is no averting of the eyes. You must look, gaze upon the wretchedness. Maybe you can close your heart off to it, forget what you've seen once the encounter ends, treat it as some detached clinical experiment, a problem to be solved empirically. For some, that is the only way to avoid involving themselves too emotionally in their patients. Regardless, open hearted or closed, you can never forget the things you see and hear and touch. It burns itself into your soul. It is the great Gift bestowed upon a physician. I wrote once about a little old lady who hid a giant fungating melanoma from her family for years as she ministered to her dying husband and how she finally broke down, opened herself up and asked for help. Those moments in my office discussing what had to be done with her and her daughters will never fade from my memory. The piercing brittleness of existence surges to the forefront of your consciousness. The things you will see. The worried, raccoon-eyed mothers in the ER with their young children right before surgery for appendicitis. The elderly husbands who dutifully sit by their intubated wives for hours in the ICU. The way a family will turn a hospital room into a shrine to the grandmother resting in bed; pictures from a foregone time when she was hale and hearty, hair a different color, crazy little scribblings from elementary-aged grandkids, fading bouquets of flowers, the rows of cards. The joy in the post operative waiting room when you tell someone everything went well, your wife is fine. The eruption of relief when you inform a woman her biopsy was benign. The quiet courage and resolve in the quivering, red-eyed visage of a woman told she has breast cancer, the husband who autonomously squeezes her hand white. The 22 year old guy who screams bloody murder when you lance a tiny boil and the old Korean war veteran who tells you about an old girlfriend he once had in Oklahoma the whole time you drain his giant perianal abscess. Broken hearted lonesome single middle aged guys who tell you not to worry about calling anyone after surgery; there's no one to call anyway. The physical maladies are no different than what you read about in textbooks. But the tapestry of human failings and strengths and triumphs you will experience as a doctor are not described in any textbooks I know of. Perhaps they are portrayed in art or literature, but the thing about art--- you never know quite to believe if it is real or not, that small nagging doubt that perhaps it's all made up. The reality of subjective experience-- it's all yours for the taking buddy. All of it is yours to observe, to learn from, to acquire. The entire spectrum of humanity on display, unadorned, vulnerable and full of absolute trust that you will do the right thing. Fear and joy and sorrow and pain and doubt and weakness reside within us all, to varying extents. You will find yourself through your experiences over a career. In Seymour, An Introduction, Seymour Glass tells his brother Buddy that all we ever do is go from one little piece of Holy Ground to the next. When you walk into a patient's room, the holy grounds open up endlessly before you. Respect where you tread.

And that's the catch. You cannot betray this gift of the Gaze. You must never forget that being a doctor is not about you. It's not a reward for getting good grades and working hard and volunteering at the local hospital. No one cares what your grades were. That AOA plaque on your office wall is meaningless to the suffering souls who come to you seeking solace. No one cares about your fellowship or that you went to Harvard or about your giant research endowment. It isn't about being president of your local medical society and making speeches. It's not about you. You owe your patients this Spartan-like self-denial. The benefits of being a physician will come to you only when you stop expecting them.

But how do you do this? How does one adopt the proper attitude necessary to handle the burden of the Gaze? What is the process? Is there a secret? How do I avoid letting it devolve into some voyeuristic sideshow? Well I think the answer is pretty simple once you get down to it. Salinger, I think, articulates it perfectly and succinctly with his admonishment to, whatever it is you've chosen to make your life's work, "do it with all your heart" and to do it for the "Fat Lady" who lives in the hearts of all men. But more on that later. First, I wanted to veer off course for a minute with two stories; one about my Aunt S. and the other about this mentally retarded developmentally delayed(MRDD) young man I saw in the hospital hallway the other week. Bear with me, please.

First, the young man. I was cruising through a long hallway on my way to the ICU, reading my patient list as I strode, when I noticed him out of the corner of my eye. He was in a wheelchair and he was washing or polishing a handrail that ran the length of the hallway. An elderly volunteer was watching him. At first I had the reflexive, complacent feeling of pity--- awww, look at the poor retarded man forced to do demeaning work in public. But I stopped further down the hall. I turned and watched him for a bit. He was sort of slouched over and his mouth was gaping and he frankly looked a little wild-eyed but he was completely focused on the task at hand. He had a rag in one hand and some sort of cleaning agent in a bottle between his legs. Very meticulously he would spray a little of the solution onto his rag and proceed to carefully wipe down the segment of railing to his right. This was drab, yellowed old railing. It would never look fantastic. And it was interminable, extending far down the length of the hallway, which curved ahead to the right so from his position you never knew when it would end. But dutifully he wiped the two foot segment in front of him, even the back side facing the wall which no one would ever see. He didn't skip areas. He wasn't careless. He concentrated. He did a fine job. There wasn't anything demeaning about it at all. Feeling sorry for him just disrespected his efforts. All work is worthy when done with the clean, humble, simple state of mind of the pure-hearted. It doesn't matter what it is. Taking out a gallbladder. Paving a highway. Cleaning a toilet. Polishing a unpolishable railing. It's all the same. We all have our opportunities to match the efforts of that young retarded guy. As doctors we're no different. It's easy to just go through the motions sometimes, to zip through an exam, to cut off a patient who rambles on about an unrelated topic during an office visit. But you can't do that, at least not with any sort of regularity. Every patient we see, every surgery is just another small segment of never-ending hallway railing to be polished as well we can, with all our hearts.

My Aunt S. was an amazing woman. She wasn't famous or renowned or anything. She was just a very loving, loyal, dedicated woman who constantly put the needs and desires of others above her own. She was always someone's biggest fan. Once she was on your side, you had an iron willed supporter for life. She was one of those people who, if something really terrific or fortunate or wonderful happened to you, she would be unconditionally happy and excited for you. There were never any strings attached. The older you get, the more you realize how rare a human trait that is. The majority of people are unable to feel such pure and unadulterated joy for the triumphs of someone else. Too often the moment is tainted by jealousy. It isn't that you aren't happy for that person. You are. But a small part of you sort of wishes such good fortune were happening to you instead and an incorrigible voice deep within will whisper things like "oh, she just knows the right people" or "his parents were able to pay for all his schooling" or "she's just about the luckiest son of a gun I know". The majority of us succumb to covetousness and an overly competitive drive to have all the happiness in the world for ourselves. My aunt was different. She could feel and internalize the joys and victories of another person as if they were her own. The moment I remember most about my Aunt S. was my medical school graduation day. My crazy family had all made the long trip to Toledo for the ceremony and of course they all got there late and had to settle for seats way high up in the rafters. I remember being next in line, waiting for my name to be called so I could walk out across the stage to get my diploma and already there was a commotion coming from somewhere back in the crowd. I couldn't see because it was so dark, like looking into a murmuring abyss. And then I was announced and there was this eruption of screaming and yelling from somewhere in the rafters. It was so loud and crazy and tumultuous I remember seeing parents in the front rows laughing amongst themselves. But one voice stood out. I distinctly remember hearing someone screaming "way to go Jeffer!!!!" My Aunt S. had always called me Jeffer, ever since I had been a little boy. Specifically, I heard her strident, exuberant voice above the cluttered din of screeches and yells. I turned to that spot up in the rafters and waved into the darkness, smiling like madman the whole time. Two years later she developed a lump in her breast that turned out to be cancer. A couple years after the mastectomy, the disease recurred. She battled for another year or two and then she started to deteriorate. She died two years ago this March. Now I wasn't such a wonderful nephew to her. I didn't call her on her birthdays. I didn't even know when her birthday was. I never bought her gifts. I never looked to her for worldy advice or professional guidance or anything like that. I was her only nephew though and she loved me in a way that I can only now truly appreciate.

These two stories best illustrate the two aspects of "doing something with all your heart". It's a delicate fusion of an almost dispassionate utter seriousness, as if what you were doing was the most important thing in the world no matter how banal and tedious it seems, along with an exuberant joy in seeing someone through a period of illness, a joy that transcends anything that has to do with you. One of my favorite passages in all of Salinger is from Seymour, an Introduction where Seymour writes to his brother Buddy about what it takes to be a great writer. The advice could apply to anyone, no matter what your career aspirations. So forgive me a little poetic license to paraphrase old Seymour in doling out some words of wisdom to all those young peope out there who are contemplating pursuing their life's work in the field of medicine:

When you die and the Man up in the sky reviews your oeuvre, do you know what He will ask you? One thing he won't ask is how many honor societies you were a member of, that's for sure. He won't ask how fast or fantastic of a surgeon you were or how marvelous of a diagnostician you were. He won't care about your awards or diplomas or honorariums. He won't ask if your patients loved you or just sort of respected you. He won't ask if you were nice to all your co-workers and colleagues. He won't ask how many medical missions you went on or how many indigent patients you treated. I mean, those things are nice and all and certainly worth aiming for. But He won't ask you about those things. You'll get asked two things and two things only: were all your stars out and did you practice medicine every day with all your heart? That's it. It doesn't get any more complicated than that. So to all of you thinking about venturing off into this holy profession you better make damn sure your skies are clear and your stars are shining bright. Keep your eyes peeled for that secret and mysterious Fat Lady who lives deep in the souls of all men--- she can be quite beautiful. And listen close for the exuberant scream of unconditional joy and love coming down from the rafters of your own lives....

I am one of countless of your anonymous readers. Your blog has been on my Google Reader feed for ages and once in a while I think about removing it as you are postless for a time or you post things I don't understand. Then you come up with something like this and I realize I'm willing to read whatever you write as long as you are willing to write it.

Second year medical student and a long time anonymous reader. I usually don't comment on such things but this post was excellent. Thank you for reminding us that while the road is hard, and that no matter what "they" it doesn't really get any easier, we can still control our attitude toward our practice of medicine. Thank you again for the excellent post.

Second year medical student and a long time anonymous reader. I usually don't comment on such things but this post was excellent. Thank you for reminding us that while the road is hard, and that no matter what "they" it doesn't really get any easier, we can still control our attitude toward our practice of medicine. Thank you again for the excellent post.

I am one of you not so anonymous readers. I have read everything you've ever posted. I don't always agree with you, but I respect all that you have written. I must say that this treatise is one of your finest works.

I am not sure if it makes me feel any better or worse about our chosen profession. I do know that I have told countless people that I feel Surgery is the best professions in the world. However, it is also one of the worst careers. In other words, I love the art and science of what I do, but lament the business. I continue to look for how I can best apply my craft. I am not sure if I am trying to ensure all my stars are shining bright or if this is all merely a Sisyphean challenge. Nonetheless, great post.JFS http://fastsurgeon.blogspot.com

Excellent writing, Salinger is knotting his head in accordance right now, he couldn't have said it better himself. I feel the same way, nothing else matters, it is about doing it with all your heart. Always.

Glad I kept reading...was about to open a vein till I got to the good part. And even though it's not THE best job in the world(A-Rod's got that) its still pretty good, where else can you have Hot Young Chicks come into your office for free BRINGING you stuff???And in any other job if you rub someones chest with conducting gel, Yell "Clear" and shock them with 300 Joules, you'll get arrested and fired...Keep up the great work JD..

Another MS2 here, wrapping up another one of those rough finals hurdles. 9 tests over 2 weeks this time, and more than once we were treated to a surprise of something being "unfair" or an unexpected, undeserved academic slap to the face.

It's enough to drive you to anger, if you don't remember things like this. Thanks for the perspective piece, and please keep writing.

I too am a anonymous reader and I must say that your post was truly inspirational and helped me put my 'hospital pharmacist' role with hits/misses and frustrations and worry about the medication events into a much better perspective. Kudos to you and your work.

Beautifully written, Jeff. I wouldn't know which superlative to use if I had to praise this piece. I hope every practising and aspiring doctor reads and internalises this.

I, like you, read "The Catcher…" in my early twenties. I was in my second year of medical college then, and I loved it. The day I learnt JD died, I listened to the audiobook version of "The Catcher…" in his honour. My personal version of "doing something with all one's heart" is "Living IN the moment. Completely."

OK, its been 24 hours, so I'll point out the Elephant Turd in the Room..."Catcher in the Rye" SUCKED!!!!! And I read it, well at least the first sentence... "If you really want to here about it...."Well I DIDN'T want to here about it, and but I read it anyway, if only cause the Cliff's Notes version was longer than the actual book...and I beat up a kid named "Holden" just cause his name reminded me of the hours I wasted reading that Drivel. That being said, Nice post,

Buckeye, once again you demonstrate the great talent you have for writing, which leaves me with the troubling thought that someday you, like most previous great physician-writers, will want to choose between writing and doctoring. Please put that choice off for as long as you find it endurable. Granted there are other docs who can be there and do the needed operation as well as you do, but I venture there are very few who can interpret and share it with posterity as well as you do.

Inspiring stuff, but I think I'm still going to resign. I think psychiatry is where I belong. The connection with patients and families in their most acutely trying and vulnerable times is all I really like about surgery anyway, well, that and taking time to conscientiously explain medical things to them like a person. Sounds like you can relate.

Great post and thanks for pointing out the amazing and rewarding daily drama of the human condition.

Oh, my. You have put my own feelings and thoughts and aspirations as a physician into one beautiful essay. I will keep your words nearby and reread them when the bad stuff gets waist deep, or higher. Thank you!

I just got into medical school, and this post expresses so much of why I feel compelled to go down this path. There are easier things to do in life, but if they don't allow me to reach the depths of compassion, understanding and self-awareness that you express, I won't get much out of life. I will read this when I need to re-center myself. Thank you for that.

One last anonymous comment. This was a great post. It is amazing how fast we lose sight of what matters in medical school. Third year at my schools is the first time we are really graded, and all of our hyper competitive type-A-ness comes out of the woodwork. It is also the first time we have patients. It made me sick on my medicine clerkship when I realized I could get more scut done and get better evaluations if I spent about 30 seconds per day with my patients.

It's hard to keep perspective but occasional reflection is key. Glad to have you around Buckeye.

As a MS1, I understand how the naivete and feeling of being 'chosen' can turn a rough corner with an intense workload and mounting debt. At the same time, it is so unbelievably important to keep the Gaze of which you speak held firmly in the mind...

Thank you so much for this wonderful post. It speaks volumes for that which I cannot put into words!

Dear Sir,I am a general surgeon in Bangladesh. 28 months back my only child, 20 yr old son, who was a medical student died from hepatitis. He was a brilliant student, topping in all exams in school and college. He was selected to study engineering in Rutgers Univ USA. But after one semester he chose to return to Bangladesh. We were all surprised, even so when he wanted to study medicine. He was as usual doing very good in all exams in Rutgers, having lot of friends and enjoying life. When I asked him why he wanted to become a doctor in Bangladesh and give up his good life in USA. He looked at me and said, "Abbu (Father), I want to be like you. I want to do good and enjoy doing it." I never understood what he meant, because I am just a simple gen surgeon going through life as best as I could. After reading your blog, I now really understand what my son meant and what he wanted to become. Thank you.My son fell sick very shortly after enrolling in a medical school and died after being in a coma for 11 days. You can have a look at his life in the facebook http://www.facebook.com/group.php?gid=21623516576

My dear friend,this piece was recommended by my colleague and i cannot thank him enough!This is probably one of the most insightful pieces of writing, i have ever come across.You are blessed with a depth of understanding and wisdom far beyond your years not to mention an enviable talent as a writer.I am grateful, you have given form to those many thoughts i share privately with friends .

What a surgeon you could be ,if you were even half as good as you think or write.

I tried like hell to find a typo - couldn't. Tried like hell to find something I didn't like about this post - couldn't. Wish I had a vocabulary like yours and realized as a former engineering student-turned doctor - couldn't say I'll ever have such.

Awesome read! It really makes me step back and observe what I have done, and what I plan to do. Right now, I am cracking away at the MCAT and pre-med frenzy of 3rd year. At times I feel overwhelmed and get the feeling of "what's the point?" However, this reminded me why I haven't quit and won't ever quit.

Dr. Parks: I am a nurse practitioner student, but I also raised three children and worked in nursing for many years before deciding to return... For almost 10 years I had the privilege of working for two general surgeons in private practice; from them I learned a great deal. Though neither could write or express what you have in your Salinger post, I thought of them while reading. It is my humble opinion that general surgeons (i.e.,good ones) are unsung heroes, quietly "doing their job" 24/7. And, I will fill in for your Aunt and tell you that you are special;the pt who enters the Ohio ER when you have call is fortunate indeed. Thank you for taking the time to share your ideas and thoughts; the internet is a bit better for it.

I'm a MD/PhD student writing (or, more accurately, procrastinating from writing) my PhD thesis right now. I've been feeling burned out, with little motivation to continue. I've been reflecting on what I've accomplished during my PhD and it seems like not much (although maybe that's just the burnout rearing its head).

One of the things I had been putting off was reading this blog post after a friend recommended it. I've literally had the tab open in my browser for over a week and haven't been able to summon the motivation to read it.

This morning I read it. For the first time in a long time I'm neither burned out nor bitter.

This post reminded me of why I'm doing what I'm doing. It reminded me of the view I had on the world after my first time reading Franny and Zooey in college. It reminded me to do it for the Fat Lady.

So thank you. It's somewhat amazing to me that a chance reading of a blog post could be precisely what I needed to read at this moment (but I guess that's why the "Unbearable Lightness of Being" sold so many copies).

As I re-enter third year med school, I'm going to try remember the perspective I now have thanks to what I've read here (which reminded me of how I was and felt before). And I'll try to remember at the toughest times in my training and practice to keep my stars shining and to do it for the Fat Lady.

An accidental tap and I was back at your site and instantly captivated by the title...excellent timing and an uplifting piece of writing. I am a GP up in Canada, one of those in danger of becoming a cog in the wheel of the primary care system and having a number of those days so well expressed by the phrase "How did I get here?"

No one goes into medical school (I hope) thinking about debt, how much they will make or many of the things I now find myself thinking of. Rather, I suspect most have clear skies and are looking to serve their fellow humans. What I most liked about your blog (and the was a lot to like) was the reminder that we, the doctors, must remember the the way the patients trust and open their lives to us is an honour and a privilege. We are the lucky ones, not them. It is this thought that will come with me into the next day, week, months and years to come as I polish my 2 feet of hallway railing over and over again. Thank you for the excellent reminder of what it is to be a member of this most challenging but excellent field.

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